, Volume 55, Issue 4, pp 413–421 | Cite as

Functional lesions in dysphagia due to acute stroke: discordance between abnormal findings of bedside swallowing assessment and aspiration on videofluorography

  • Aiko Osawa
  • Shinichiro Maeshima
  • Hiroshi Matsuda
  • Norio Tanahashi
Diagnostic Neuroradiology



Bedside swallowing assessments are often used to assess dysphagia. However, in some patients, aspiration pneumonia occurs without any problems on bedside swallowing assessments and some patients do not suffer aspiration pneumonia despite abnormal results of bedside swallowing assessments in acute stroke. To detect the differences of lesions related to bedside swallowing assessment abnormality and aspiration, we investigated swallowing-related functional lesions in terms of cerebral blood flow in patients with dysphagia after stroke.


The study included 50 acute stroke patients who underwent bedside swallowing assessments and videofluorography as well as single-photon emission computed tomography (CT) at approximately the same time. Bedside swallowing assessments included repetitive saliva swallowing test and modified water swallowing test as dry and wet swallowing tasks. The presence or absence of aspiration was assessed using videofluorography. We divided patients into three subgroups based on the outcomes of the bedside swallowing assessments and presence or absence of aspiration. Statistical image analysis was performed using single-photon emission CT to determine their relationship with bedside swallowing assessments and videofluorography results.


Twenty-seven (54.0 %) and 28 (56.0 %) patients had abnormal repetitive saliva swallowing test and modified water swallowing test results. Videofluorography indicated aspiration in 35 (70.0 %) patients. In comparing patients with and without abnormal results on each test, the groups with abnormal repetitive saliva swallowing test, abnormal modified water swallowing test, and aspiration demonstrated lower cerebral blood flow in the left precuneus, left insula, and anterior cingulate gyrus, respectively.


Based on the analysis of cerebral blood flow, functional lesions differed across abnormal repetitive saliva swallowing test and abnormal modified water swallowing test findings and aspiration on videofluorography, and each test may assess different functions among the many processes involved in swallowing.


Stroke Swallowing Dysphagia Cerebral blood flow Videofluorography 


  1. 1.
    Gordon C, Hewer RL, Wade DT (1987) Dysphagia in acute stroke. BMJ (Clin Res Ed) 295:411–414CrossRefGoogle Scholar
  2. 2.
    Horner J, Massey EW (1988) Silent aspiration following stroke. Neurology 38:317–319PubMedCrossRefGoogle Scholar
  3. 3.
    Smithard DG, O'Neill PA, Parks C, Morris J (1996) Complications and outcome after acute stroke: does dysphagia matter? Stroke 27:1200–1204PubMedCrossRefGoogle Scholar
  4. 4.
    Ickenstein GW, Stein J, Ambrosi D, Goldstein R, Horn M, Bogdahn U (2005) Predictors of survival after severe dysphagic stroke. J Neurol 252:1510–1516PubMedCrossRefGoogle Scholar
  5. 5.
    Kedlaya D, Brandstater ME (2002) Swallowing, nutrition and hydration during acute stroke care. Top Stroke Rehabil 9:23–28PubMedCrossRefGoogle Scholar
  6. 6.
    Rosenvinge SK, Starke ID (2005) Improving care for patients with dysphagia. Age Ageing 34:587–593PubMedCrossRefGoogle Scholar
  7. 7.
    Yoo SH, Kim JS, Kwon SU, Yun SC, Koh JY, Kang DW (2008) Undernutrition as a predictor of poor clinical outcome in acute ischemic stroke patients. Arch Neurol 65:39–43PubMedCrossRefGoogle Scholar
  8. 8.
    Marques CHD, de Rosso ALZ, Andre C (2008) Bedside assessment of swallowing in stroke: water tests are not enough. Top Stroke Rehabil 15:378–383PubMedCrossRefGoogle Scholar
  9. 9.
    DePippo KL, Holas MA, Reding MJ (1992) Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol 49:1259–1261PubMedCrossRefGoogle Scholar
  10. 10.
    Gottlieb D, Kipnis M, Sister E, Vardi Y, Brill S (1996) Validation of the 50 ml3 drinking test for evaluation of post-stroke dysphagia. Disabil Rehabil 18:529–532PubMedCrossRefGoogle Scholar
  11. 11.
    Oguchi K, Saitoh E, Baba M, Kusudo M, Tanaka T, Onogi K (2000) The repetitive saliva swallowing test (RSST) as a screening test of functional dysphagia (2). Validity of RSST. Jpn J Rehabil Med 38:383–388CrossRefGoogle Scholar
  12. 12.
    Tohara H, Saitoh E, Mays KA, Kuhlemeier K, Palmer JB (2003) Three tests for predicting aspiration without videofluorography. Dysphagia 18:126–134PubMedCrossRefGoogle Scholar
  13. 13.
    Smithard DG, O’Neill PA, Park C, England R, Renwick DS, Wyatt R, Morris J, Martin DF (1998) Can bedside assessment reliably exclude aspiration following acute stroke? Age Ageing 27:99–106PubMedCrossRefGoogle Scholar
  14. 14.
    Trapl M, Enderle P, Nowotny M, Teuschi Y, Mats K, Dachenhausen A, Brainin M (2007) Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke 38:2948–2952PubMedCrossRefGoogle Scholar
  15. 15.
    Horner J, Buoyer FG, Alberts MJ, Helms MJ (1991) Dysphagia following brain-stem stroke: clinical correlates and outcome. Arch Neurol 48:1170–1173PubMedCrossRefGoogle Scholar
  16. 16.
    Daniels SK, Foundas AL (1997) The role of the insular cortex in swallowing. Dysphagia 12:146–156PubMedCrossRefGoogle Scholar
  17. 17.
    Steinhagen V, Grossmann A, Benecke R, Walter U (2009) Swallowing disturbance pattern relates to brain lesion location in acute stroke patients. Stroke 40:1903–1906PubMedCrossRefGoogle Scholar
  18. 18.
    Martin RE, Goodyear BG, Gati JS, Menon RS (2001) Cerebral cortical representation of automatic and volitional swallowing in humans. J Neurophysiol 85:938–950PubMedGoogle Scholar
  19. 19.
    Cola MG, Daniels SK, Corey DM, Lemen LC, Romero M, Foundas AL (2010) Relevance of subcortical stroke in dysphagia. Stroke 41:482–486PubMedCrossRefGoogle Scholar
  20. 20.
    Li S, Luo C, Yu B, Yan B, Gong Q, He C, He L, Huang X, Yao D, Lui S, Tang H, Chen Q, Zeng Y, Zhou D (2009) Functional magnetic resonance imaging study on dysphagia after unilateral hemispheric stroke: a preliminary study. J Neurol Neurosurg Psychiatry 80:1320–1329PubMedCrossRefGoogle Scholar
  21. 21.
    Shinohara Y, Yanagihara T, Abe K, Yoshimina T, Fujinaka T, Chuma T, Ochi F, Nagayama M, Ogawa A, Suzuki N, Katayama Y, Kimura A, Liu M, Eto F (2011) VII. Rehabilitation. J Stroke Cerebrovasc Dis 20:S145–S180PubMedCrossRefGoogle Scholar
  22. 22.
    Tsubahara A, Tanimoto K, Baba M (2004) Standard method for videofluorography: the Japanese Society of Dysphagia Rehabilitation. JJDR (Japanese Journal of Dysphagia Rehabilitation) 8:71–86Google Scholar
  23. 23.
    Matsuda H, Yagishita A, Tsuji S, Hisada K (1995) A quantitative approach to technetium-99 m ethyl cysteinate dimer: a comparison with technetium-99 m hexamethylpropylene amine oxime. Eur J Nuc Med 22:633–637CrossRefGoogle Scholar
  24. 24.
    Friston KJ, Holmes AP, Worsley KJ, Poline JP, Frith CD, Frackowiak RS (1995) Statistical parametric maps in functional imaging. Hum Brain Map 2:189–210CrossRefGoogle Scholar
  25. 25.
    Côté R, Hachinski VC, Shurvell BL, Norris JW, Wolfson C (1986) The Canadian Neurological Scale: a preliminary study in acute stroke. Stroke 17:731–737PubMedCrossRefGoogle Scholar
  26. 26.
    Lewell SY, Reynolds RC, Chen G, Horwitz B, Ludlow CL (2012) Functional connectivity and laterality of the motor and sensory components in the volitional swallowing network. Exp Brain Res 219:85–96CrossRefGoogle Scholar
  27. 27.
    Meng NH, Wang TG, Lien IN (2000) Dysphagia in patients with brainstem stroke: incidence and outcome. Am J Phys Med Rehabil 79:170–175PubMedCrossRefGoogle Scholar
  28. 28.
    Meadows JC (1973) Dysphagia in unilateral cortical lesions. J Neurol Neurosurg Psychiatry 38:853–860CrossRefGoogle Scholar
  29. 29.
    Jacobson DL, Bica I, Knox TA, Wanke C, Tchetgen E, Spiegelman D, Silva M, Gorbach S, Wilson IB (2003) Difficulty swallowing and lack of receipt of highly active antiretroviral therapy predict acute weight loss in human immunodeficiency virus disease. Clin Infect Dis 37:1349–1356PubMedCrossRefGoogle Scholar
  30. 30.
    Okamura N, Maruyama M, Ebihara T, Matsui T, Nemoto M, Arai H, Sasaki H, Yanai K (2004) Aspiration pneumonia and insular hypoperfusion in patients with cerebrovascular disease. J Am Geriatr Soc 52:645–646PubMedCrossRefGoogle Scholar
  31. 31.
    Schroeder MF, Daniels SK, McClain M, Corey DM, Fondas AL (2006) Clinical and cognitive predictors of swallowing recovery in stroke. J Rhabil Res and Development 43:301–303CrossRefGoogle Scholar
  32. 32.
    Sellars C, Bowie L, Bagg J, Sweeney P, Miller H, Tinlston J, Langhorne P, Stott DJ (2007) Risk factors for chest infection in acute stroke: a prospective cohort study. Stroke 38:2284–2291PubMedCrossRefGoogle Scholar
  33. 33.
    Matsuda H, Mizumura S, Nagao T, Ota T, Iizuka T, Nemoto K, Takemura N, Arai H, Homma A (2007) Automated discrimination between very early Alzheimer disease and controls using an easy Z-score imaging system for multicenter brain perfusion single photon emission tomography. Am J Neuroradiol 28:731–736PubMedGoogle Scholar
  34. 34.
    Daniels SK, Foundas AL, Iglesia GC, Sullivan MA (1996) Lesion site in unilateral stroke patients with dysphagia. J Stroke Cerebrovasc Dis 6:30–34PubMedCrossRefGoogle Scholar
  35. 35.
    Soros P, Lalone E, Smith R, Stevens T, Theurer J, Menon RS, Martin RE (2008) Functional MRI of oropharyngeal air-pulse stimulation. Neurosci 153:1300–1308CrossRefGoogle Scholar
  36. 36.
    Warabi T, Ito T, Kato M, Takei H, Kobayashi N, Chiba S (2008) Effects of stroke-induced damage to swallow-related areas in the brain on swallowing mechanics of elderly patients. Geriatr Gerontol Int 8:234–242PubMedCrossRefGoogle Scholar
  37. 37.
    Geldberg G (1985) Supplementary motor area structure and function: review and hypothesis. Behav Brain Sci 8:567–615CrossRefGoogle Scholar
  38. 38.
    Watanabe Y, Abe S, Ishikawa T, Yamada Y, Yamane GY (2004) Cortical regulation during the early stage of initiation of voluntary swallowing in humans. Dysphagia 19:100–108PubMedCrossRefGoogle Scholar
  39. 39.
    Hamdy S, Milkulis DJ, Crawley A, Xue S, Lau H, Henry S, Diamant NE (1999) Cortical activation during human volitional swallowing: an event-related fMRI study. Am J Physiol 277:G219–225PubMedGoogle Scholar
  40. 40.
    Maeshima S, Osawa A, Takajo F, Kurozumi S, Ota N, Kumakura I (2007) A comparison study of aspiration with clinical manifestations in stroke patients. Brain Nerve (Tokyo) 59:521–526Google Scholar
  41. 41.
    Ramsey DJ, Smithard DG, Kalra L (2003) Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke 34:1252–1257PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Aiko Osawa
    • 1
  • Shinichiro Maeshima
    • 1
  • Hiroshi Matsuda
    • 2
  • Norio Tanahashi
    • 3
  1. 1.Department of Rehabilitation MedicineSaitama Medical University International Medical CenterHidakaJapan
  2. 2.Department of Nuclear MedicineSaitama Medical University International Medical CenterHidakaJapan
  3. 3.Department of NeurologySaitama Medical University International Medical CenterHidakaJapan

Personalised recommendations